Chuck Lauer: Greater Awareness of HAIs Has Not Translated Into Action
Part of the problem seems to be that a lot of people don't get excited about fighting HAIs. They should be. An estimated one out of every 20 hospitalized patients in the United States will contract an HAI, at a total cost of as much as $45 billion a year.
Twelve years ago, the Institute of Medicine released its groundbreaking report, "To Err is Human," which got hospital executives all fired up about this issue. In the report's wake, just about every hospital in the country began updating safe practices, rethinking staff training and setting up patient safety committees.
The IOM report found that preventable medical errors were causing 44,000 to 98,000 deaths per year — an astounding figure. In an analogy I remember to this day, the IOM said these deaths amounted to one jumbo jet crashing every single day of the year. If that actually happened, the airline industry would be shut down! But in healthcare, we tolerate this death toll.
A dozen years after that 1999 report, where do we stand? According to some accounts, deaths from HAIs are now much higher than the IOM's 1999 estimate. Basically, we have been treading water. Of all the infections out there, the most difficult one to control is probably Clostridium difficile, a bacteria that can cause severe diarrhea, inflammation and bleeding in the colon, and death. It strikes half a million Americans a year, and more than 9 percent of C. difficile-related hospitalizations end in death.
USA Today recently ran a sobering front-page article on U.S. hospitals' losing battle against C. difficile. It's a stubborn infection. Alcohol-based hand sanitizers and many disinfectants are ineffective in getting rid of the spores. Simply mopping hospital floors just spreads them around. Eight years after "To Err is Human," the CDC reported that the C. difficile rate in U.S. hospitals almost doubled. The rate declined a little in 2008, but the current level is still way above what it was when the IOM report opened our eyes to the enormity of this problem.
Should we give up? Is it simply impossible to punch a hole in an infection like C. difficile? Absolutely not. A number of hospitals have shown that by applying some imagination, determination and grit, it is possible to cut the infection rate substantially. In 2010, the Mayo Clinic reduced C. difficile acquisition rates by one-third in high-risk units, mainly through daily cleaning of all high-touch surfaces with a disinfectant. This doesn't need to cost a whole lot of money. Jewish Hospital-Mercy Health in Cincinnati, for example, cut its C. difficile rates in half in less than a year, at a cost of just $10,000.
But as hospitals struggle to control their bottom line, that kind of money is, in many cases, apparently too much. Even basic services that help control HAIs have been cut back. A big part of the fight against C. difficile involves maintaining adequate housekeeping staff. According to the Association for the Healthcare Environment, however, hospitals have cut housekeeping budgets by up to 25 percent in recent years. AHE surveys also found that many hospitals spend as little as 18 minutes cleaning a patient's room, well below the optimal level of 25-30 minutes.
One effective way to get hospitals interested in eradicating infections is to lower reimbursements for cases involving HAIs. But these initiatives may simply cause hospitals to shift existing resources around.
In 2008, CMS began withholding additional reimbursement for hospitalizations for just two HAIs: catheter-associated urinary tract infections and central line-associated bloodstream infections. The CMS policy was a success, in that it forced hospitals to redouble efforts against the two targeted infections, and infection rates fell. But in the process, resources were taken away from fighting other HAIs. In a recent survey by the Association for Professionals in Infection Control and Epidemiology, 81 percent of infection preventionists reported that their hospitals had focused more resources on the two targeted infections, but one-third of respondents said resources had been shifted from fighting other infections, including C. difficile.
This is robbing Peter to pay Paul. Fighting HAIs shouldn't be a zero-sum game. It's time for hospitals to take a more aggressive approach against stubborn infections like C. difficile. HAIs accounted for $40 billion in excess healthcare costs in 2009, with the average infection costing $20,000 to $25,000 to treat, according the CDC. As reimbursements move from fee-for-service to bundled payments, hospitals may be forced to swallow the high cost of HAIs or finally do something about them.
In the meantime, hospitals' uninspiring fight against C. difficile has even disillusioned HHS, which in 2008 had established optimistic five-year targets for reducing of HAIs. It slated a 30 percent reduction for C. difficile hospitalizations by 2013, but now, one year before that deadline, HHS concedes there us no way that goal can be reached.
Government must take a stronger stand to eradicate stubborn infections like C. difficile. The British government requires hospitals to report all C. difficile cases –– part of a regulatory campaign that has reduced infections by more than 50 percent since 2008. In the United States, a new C. difficile reporting rule for facilities will take effect next year. Thirty-four states now require hospitals to publicly report their rates of infections, but fewer than a quarter of them include C. difficile, according to an analysis by HAI Focus.
For the past dozen years, we have seen greater awareness of the massive destruction wreaked by HAIs like C. difficile. Now we need to finally do something about it.
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